Prescription Drug Abuse. The term “doctor shopping” has traditionally referred to a patient obtaining controlled substances from multiple health care.

Oklahoma PMP

Prescription Drug Abuse

The term “doctor shopping” has

traditionally referred to a patient obtaining controlled substances from multiple health care practitioners without the prescribers’ knowledge of the other prescriptions.

Definition

Almost all states have a “general” fraud

statute that adopts verbatim or with slight alteration the provision in the Uniform Narcotic Drug Act of 1932 or the Uniform Controlled Substances Act of 1970. These statutes prohibit obtaining drugs, including through “doctor shopping,” by any or all of the following means: fraud, deceit, misrepresentation, subterfuge, or concealment of material fact.

National Restrictions

Applicable Laws

Category Legal CitationPhysical Examination/ Patient Physician Relationship

Okla. Stat. tit. 59, § 509Okla. Admin. Code § 535:15-3-13

Tamper-Resistant Forms Okla. Admin. Code § 317:30-5-70.2

Prescription Limits Okla. Admin. Code § 317:30-5-77.1

ID Requirement Okla. Admin. Code § 475:30-1-15

Okla. Stat. tit. 63, § 2-309C

Okla. Stat. tit. 63, § 2-309B

Doctors say they often rely on their own instant

judgments in the office and have little reliable means of double-checking the patients' information

It puts doctors in the uncomfortable position of playing private eye.

Unfortunately, with the widespread misuse of controlled substances and diversion risks, we're often taken advantage of

Doctor shoppers often visit facilities where medical professionals don't know them

How PMP’s Can Help

Patients who have pain but cannot not find a

doctor who will adequately treat it Patients who are addicted Patients who divert prescription drugs for

profit and/or to feed their addiction

Types of Doctor Shoppers

It's a relatively insignificant source of diverted prescription drugs, as compared with theft from drug stores, warehouses, acquisition over the Internet, theft from people's homes

What Every Pharmacists Should Know

Stolen Script Pads Reproduced Script Pads Early Fills Cash Fills vs. Insurance Pill Mills Script Mills Scripts Called In

Fraud and Forgery

Period 5/

56/6

7/7

8/8 9/9

10/10

15/15

Notes

Q1 2010 524

224

98 46 25 17 2 Online system in place 3 ½ years by this point.  Data collected every 30 days

Q2 2010 658

272

140

77 44 24 3  

Q3 2010 811

344

141

75 46 27 2  

Q4 2010 656

280

128

60 32 20 1 Daily Reporting Begins

Q1 2011 630

246

117

59 32 13 1  

Q2 2011 596

258

112

58 30 18 4  

Q3 2011 649

232

101

40 21 9 0  

Q4 2011 475

162

79 40 14 5 0 Voluntary Real-Time Reporting Begins

Q1 2012 478

168

72 33 17 10 0 Real-Time Reporting Required

Q2 2012 424

147

49 21 9 3 0 Four Online Alerts Broadcast on Specific Patients (Unsolicited Reports Pending)

Oklahoma Shoppers

In general, the number of doctor shoppers represent

a very small number of total patients A study in West Virginia found that doctor shoppers

are at a much higher risk of death from overdose and abuse

Doctor shoppers divert care from legitimate patients especially in emergency rooms

In Oklahoma, a single doctor shopper visited 108 doctors and 93 pharmacies in less than a year

Prescribing more doses than needed increases opportunity

Impact

A statewide electronic database that gathers

information from dispensers of controlled substances Pharmacies Doctors Veterinarians

A tool used to guard against the diversion of controlled drugs

A diagnostic tool used by practitioners to evaluate patients

A research tool to identify trends and help identify solutions

PMP’s and What They Do

Controlled Drugs in Oklahoma

Pain Killers58%Sedatives

13%

Stimulants10%

Tranquilizers19%

2011 Prescriptions by Therapeutic Class

Trends

Year 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013

Oxycodone

NaN 264551

282545

304928

300396

342269

472881

512376

578256

619458

673645

719294

762572

250,000

350,000

450,000

550,000

650,000

750,000

Oxycodone Prescription Totals (Tabs and Capsules Only)

# o

f Scri

pts

#1 Hydrocodone

1H 08 2H 08 1H 09 2H 09 1H 10 2H 10 1H 11 2h 11 1h 12 2h 12 1h 13 2h 13

Total

61319853

66266746

74173925

78701892

75586470

81456696

88388437

93797045

96141811

93185651

96003738

97361650

62,500,000

67,500,000

72,500,000

77,500,000

82,500,000

87,500,000

92,500,000

97,500,000

Hydrocodone (2008 - 2013)

Tota

ls

According to the National Institutes of Health, approximately 30 percent of all

Americans complain of sleep disruption, while 10 percent display symptoms congruent with chronic insomnia. One of the most common treatments for insomnia is prescription sleep medications that help people fall asleep and remain asleep. Historically barbiturates were initially popular for treating insomnia, but their long "hangover" effect made them easily replaced with the introduction of the benzodiazepines. Triazolam (Halcion), diazepam (Valium), and oxazepam (Serax) rapidly became the treatment of choice for insomnia. Recently a new class of nonbenzodiazepines---the "z-sedatives"--has overtaken the older benzodiazepines as the most commonly prescribed sleep medications. The three most popular z-drugs are zolpidem (Ambien), zaleplon (Sonata), and eszopiclone (Lunesta). The Food and Drug Administration (FDA) also recently approved the production of zolpidem tartrate, a generic form of Ambien. Many dentists prescribe these medications for patients who have difficulty sleeping the night prior to an appointment or as a procedural sedative. With 43 million prescriptions for sleep medications filled in 2005, generating $2.7 billion for pharmaceutical companies, it is important that dentists be aware of these drugs' mechanism of action and potential drug interactions.

http://www.ncbi.nlm.nih.gov/pubmed/18069595

The Rise of z-Sedatives

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1993866/

Some combinations of drugs can be dangerous

and even deadly. Mixing benzodiazepines and opiates can be extremely dangerous. Both benzos and opiates are central nervous system depressants. When taking both a benzodiazepine, such as lorazepam, and an opiate like morphine, the drugs can lead to excessive depression of the nervous system, causing respiratory depression and ultimately death.

http://www.desmoinesaddictiontreatment.com/rehab-guide/dangers-of-using-benzodiazepines-with-opiates/

Opiates and Benzos

According to the evidence, there is a positive

association between the risk of death and the use of benzodiazepines in combination with methadone. Though limited, there is an indication that opioids, including buprenorphine, have the potential for increased risk in combination with benzodiazepines. Clinical mechanisms are hypothesized.

- See more at: http://www.thementalelf.net/mental-health-conditions/anxiety-disorders/is-it-safe-to-prescribe-benzodiazepines-and-opioids-together/#sthash.L92Va1MB.dpuf

Opiate/Benzo Research

“UserX had this happen to him when he never did benzos

 (oxy+diazapam). the high was no where near as good as pure OC. now he cant do opiates without wanting benzos, its like the high is incomplete. but now hes a benzo addict...”

“My doctor has me on 8 MG of Xanax daily. (QID) 2 MG. Xanax bars) then for my spinal infection Percocet 10/325 6 times a day. Im also on Zoloft 200 MG's a day... im only 27 years old and i feel like i am 50 years old. Im going to ask to be switched to Valium again because of the rebound anxiety i get with Alprazolam.. i also live in the state of CALIFORNIA i possess my Prop 215 Card for Medicinal Cannabis(i feel Cannabis is the best medicine for anxiety and severe pain HANDS DOWN!!!! im allowed to exceed the limit on my card. i can possess 6 pounds of buds, and grow up to 90 plants. I love California”

Real Conversations from Drug Seekers

DrX

8th in Schedule II Prescribing 1st in Scehdule III Prescribing 1st in Scheudle IV Prescribing At one point was writing nearly 3% of all opiates

dispensed in Oklahoma 10+ Overdose Deaths Multiple Counts of Murder Previous felony convictions involving controlled

drugs Motivation?

When Overprescribing Becomes Criminal

More than 100mg of morphine equivalent per

day increases the risk of death by overdose by 9 times.

Direct correlation between mortality and morphine equivalent

Opiate Naïve Patients

Morphine Equivalent

Nationally Recognized as the Leaders in

Innovation and Leadership Among State PMP’s Real Time Reporting by Dispensers (Within 5 Minutes)

Practitioner Use up 167% Pharmacy Use up 1,085% Law Enforcement/Regulatory Use up 60%

For the 1st Time in the Last Two Years Accidental Overdose Deaths have Declined

Full Time PMP Trainer Hired De-Identified PMP Data Being Provided to ODMHS Nov.

1, 2013

Making a Difference

Question and Listen Challenge and Communicate Risk Experimentation Reflect Consider Dynamics Inside and Outside the

Organization Be Authentic Be Outcome Driven Dare to Imagine

Leadership and Innovation

Interstate Data Sharing (November 1, 2014) Access by Federal Medical Professionals

without being Registrants Enumerated Delegate Accounts Mandatory PMP Queries

New Processes Recommended prescribing guidelines Prescriber dispensing education

New Laws

We cannot solve a

problem by using the same kind of thinking we

used when we created them. [A. Einstein]

Vision